8816 - South African Civil Aviation Authority

Section/division Occurrence Investigation Form Number: CA 12-12a
AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY
Reference: CA18/2/3/8816
Aircraft Registration ZS-RME Date of accident 02 July 2010 Time of Accident 1345Z
Type of Aircraft Eurocopter EC 120B Type of Operation Training
Pilot-in-command Licence Type Airline transport Age 43 Licence Valid Yes
Pilot-in-command Flying Experience Total Flying Hours 6 895.4 Hours on Type 75.6
Last point of departure Cape Town international airport - FACT (Western Cape province).
Next point of intended landing Cape Town international airport – FACT (Western Cape province).
Location of the accident site with reference to easily defined geographical points (GPS readings if possible)
General fling area at GPS position determined as South 33 o 58’ 12.34” East 18 o 36’ 34.30”.
Meteorological Information Surface wind 190° @ 5 knots, temperature 22°C, visibility +10 km.
Number of people on board 1 + 1 No. Of people injured 0 No. Of people killed 0
Synopsis
The helicopter with two certified pilots was involved in a training flight under Visual Flight Rules
(VFR) by day. Both pilots performed a comprehensive pre-flight inspection and the aircraft was
uplifted with aviation gasoline Jet A1. Take-off was normal and the aircraft headed towards Cape
Town International general flying (GF) area for training purpose. It was a 6 th –monthly operator’s
proficiency check (OPC) for the co-pilot (A trainee at the time of the accident). They started with
the simulation of hydraulic failure followed by three simulated engine failure in hover. They
climbed to 1000 feet above ground level (AGL) for autorotation practices. The first autorotation
went well with the instructor closing the twist grip to ground idle and the trainee going into
autorotation. The instructor again opened the twist grip to flight position during flare. The second
autorotation was from a downwind position at 1000 feet AGL. The instructor closed the twist grip
to ground idle and the trainee went into autorotation. The instructor looked at the Main rotor and
Engine N2 (NR/NF) gauge and checked if the main rotor Revolution per Minute (RPM) was under
control. The instructor then noticed that the engine RPM was winding down below normal idle
indication. The instructor informed the trainee that they have lost an engine and the trainee
continued with the normal procedures for autorotation till touchdown. On touchdown the aircraft
still had a forward motion, skidded for approximately 3 meters. The speed reduced quite quickly
as the skids dug into the soft terrain and the tail boom was chopped off by the main rotor. The
aircraft was substantially damaged and no one was injured.
Probable Cause
Unsuccessful autorotation resulting into hard landing due to undetermined loss of engine power.
IARC Date
Release
Date
CA 12-12b 23 FEBRUARY 2006 Page 1 of 13

Section/division
Occurrence Investigation Form Number: CA 12-12a
Telephone number: 011-545-1408 E-mail address of originator:
AIRCRAFT ACCIDENT REPORT
Name of Owner/Operator : Titan Helicopters
Manufacturer : Eurocopter
Model : Eurocopter EC 120B
Nationality : South African
Registration Marks : ZS-RME
Place : Cape Town International
Date : 02 July 2010.
Time : 1345Z
All times given in this report is Co-ordinated Universal Time (UTC) and will be denoted by (Z). South African
Standard Time is UTC plus 2 hours.
Purpose of the Investigation:
In terms of Regulation 12.03.1 of the Civil Aviation Regulations (1997) this report was compiled in the interest of
the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and not to
establish legal liability.
Disclaimer:
This report is given without prejudice to the rights of the CAA, which are reserved.
1. FACTUAL INFORMATION:
1.1 History of flight:
1.1.1 The helicopter with two licensed pilots was involved in a training flight under Visual
Flight Rules (VFR) by day. Both pilots performed a comprehensive pre-flight inspection
and the aircraft was uplifted with aviation gasoline Jet A1. Take-off was normal and the
aircraft headed towards Cape Town International general flying (GF) area for training
purpose. It was a 6 th –monthly operator’s proficiency check (OPC) for the co-pilot
(trainee at the time of the accident). They started with the simulation of hydraulic
failure followed by three simulated engine failure in hover. They climbed to 1000 feet
above ground level (AGL) for autorotation practices. The first autorotation went well
with the instructor closing the twist grip to ground idle and the trainee going into
autorotation. The instructor again opened the twist grip to flight position during flare.
The second autorotation was from a downwind position at 1000 feet AGL.
1.1.2 The instructor closed the twist grip to ground idle and the trainee went into
autorotation. The instructor looked at the Main rotor and Engine N2 (NR/NF) gauge
and checked if the main rotor Revolution per Minute (RPM) was under control. The
instructor then noticed that the engine RPM was winding down below normal idle
indication. The instructor informed the trainee that they have lost an engine and the
trainee continued with the normal procedures for autorotation till touchdown. On
touchdown the aircraft still had a forward motion, skidded for approximately 3 meters.
The speed reduced quite quickly as the skids dug into the soft terrain and the tail boom
was chopped off by the main rotor. Debris was noticed flying out to the left of the
aircraft and the aircraft was substantially damaged.
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1.1.3 The airport Air Traffic Control (ATC) was notified of the situation and the airport crash
alarm was immediately activated. The airport fire and rescue services dispatched to
the accident site and both pilots vacated the aircraft unharmed. The accident
happened during daylight conditions at GPS position determined to be S33 o 58’ 12.34”
E18 o 36’ 34.30”.
1.2 Injuries to persons:
Injuries Pilot Crew Pass. Other
Fatal - - - -
Serious - - - -
Minor - - - -
None 2 - - -
1.3 Damage to aircraft:
1.3.1 The main rotor blades made contact with the tail boom and the tail boom was chopped
off. The main rotor blades were damaged, the pitot tube was damaged and the right
hand wind screen broke during the accident sequence. Note: In order to determine the
full extent of the damage, the helicopter would have to undergo extensive inspection
due to the unknown stresses placed on the airframe and the skids.
Figure 1: View of the helicopter at the accident site.
1.4 Other damage:
1.4.1 Nil.
CA 12-12b 23 FEBRUARY 2006 Page 3 of 13

1.5 Personnel information:
Trainee: (Pilot flying).
Nationality South African Gender Male Age 43
Licence Number ########### Licence Type Airline transport
Licence valid Yes Type Endorsed Yes
Ratings
Night Rating, Instrument Rating, Instructor Rating,
Under Sling, Winching and Test pilot rating.
Medical Expiry Date 31 October 2010
Restrictions None
Previous Accidents Nil
Flying experience:
Total Hours 6895.4
Total Past 90 Days 5.7
Total on Type Past 90 Days 51.0
Total on Type 75.6
Instructor: (Pilot not flying).
Nationality South African Gender Male Age 57
Licence Number ############ Licence Type Airline transport
Licence valid Yes Type Endorsed Yes
Ratings
Night Rating, Instrument Rating, Instructor Rating,
Under Sling, Winching and Test pilot Rating.
Medical Expiry Date 30 September 2010
Restrictions Corrective lenses
Previous Accidents Nil
Flying experience:
Total Hours ±10400
Total Past 90 Days 10
Total on Type Past 90 Days 0.4
Total on Type ±600
1.6 Aircraft information:
Aircraft description:
An EC 120B is a medium five-seat helicopter, powered with a three-blade
rotor system. It is manufactured in Turbomecca France and frequently used as a lowcost
aircraft.
CA 12-12b 23 FEBRUARY 2006 Page 4 of 13

Airframe:
Type EC 120B
Serial No. 1132
Manufacturer Eurocopter
Date of Manufacture 2000
Total Airframe Hours (At time of accident) 2149.8
Last MPI (Hours & Date) 2139.4 07 April 2010
Hours since Last MPI 10.4
C of A (Issue Date) 29 September 2000
C of A (Expiry Date) 28 September 2010
C of R (Issue Date) (Present owner) 03 October 2010
Operating Categories Standard
A´D and S´B Status Complied
Aircraft Weight 1800 kg
Recommended fuel used Jet A1
Note: The last MPI (Mandatory periodic inspection) that was carried out on the
helicopter prior to the accident was certified at 2131.4 hours on 07 April 2010 by the
AMO (Aircraft Maintenance Organisation). The person who certified the task held a
valid approved person accreditation from the CAA as well as an AME (Aircraft
Maintenance Engineer) licence.
Previous Accidents
and Incidents
Engine:
On 10 October 2001 at 1150Z. The fuel vehicle was
parked next to the helicopter and a gust of wind rotated
the main rotor blades which subsequently made contact
with the fuel vehicle׳s roll bar.
On 03 December 2001 at Grand Central aerodrome
(1500Z). After shut down before the pilot pulled the rotor
brake, he opened the pilot door and the wind pulled the
door fully opened damaging the door and the window.
Type Turbomecca Arriuss 2F
Serial No. 34143
Hours since New 2149.4
Hours since Overhaul Not reached
1.7 Meteorological information:
1.7.1 The following weather information was obtained from the pilot questionnaires.
Wind direction 190º Wind speed 5 Knots Visibility 10km
Temperature 22ºC Cloud cover Few Cloud base 10.000
Dew point 10ºC
CA 12-12b 23 FEBRUARY 2006 Page 5 of 13

1.8 Aids to navigation:
1.8.1 The helicopter was fitted with standard navigation equipment for this helicopter type as
approved at the time of certification.
1.9 Communications:
1.9.1 No difficulties with communications were known or reported prior to the accident. No
malfunction of any of the equipment was reported at the time of the accident.
1.10 Aerodrome information:
Aerodrome Location Cape Town International
Aerodrome Co-ordinates S33º 58׳05.2׳ E018º 36׳16.7׳.
Aerodrome Elevation 151 feet AMSL
Aerodrome Status Licensed
Runway Designations 01/19 3 322 x 300
Runway Dimensions 16/34 1 820 x 150
Runway Used Runway 34
Runway Surface Asphalt
Approach Facilities PAPI, NDB,ILS, VOR, DME, Runway lighting
1.11 Flight recorders:
1.11.1 The helicopter was not fitted with a flight data recorder (FDR) or a cockpit voice
recorder (CVR), neither was it required in terms of the South African Civil Aviation
Regulations to be fitted to this aircraft type.
1.12 Wreckage and impact information:
1.12.1 The aircraft landed on threshold runway 34 and after landing the tail boom was
chopped off. The wind screen was damaged, pitot tube was damaged and the main
rotor blades were damaged during the accident sequence. The position of the twist
grip was on fully open position (flight idle) at the time of inspection and the indication
on the fuel control unit (FCU) quadrant was on 60º.
CA 12-12b 23 FEBRUARY 2006 Page 6 of 13

Figure 2: Position of the twist grip as found after the accident.
Figure 3: Quadrant position on 60º.
1.12.2 The fuel shut off valve was found in OFF/Closed position.
CA 12-12b 23 FEBRUARY 2006 Page 7 of 13

Figure 4: View of the fuel shut off valve on the aircraft cockpit roof.
1.13 Medical and pathological information:
1.13.1 Both pilots sustained no injuries as result of this accident.
1.14 Fire:
1.14.1 There was no evidence of pre- and post-impact fire
1.15 Survival aspects:
1.15.1 The accident was considered survivable because both occupants were properly
restrained and secured by making use of safety harnesses.
1.15.2 The cockpit/cabin area remained intact after the accident sequence.
1.16 Tests and research:
1.16.1 After the accident the aircraft was recovered by a crane to the hanger where further
investigation were carried out by two certified Engineers under the auspices of the SA
CAA accident investigators.
INSPECTIONS PERFORMED:
They checked if they could turn the twist grip to off position without
powering the aircraft and it was not possible.
CA 12-12b 23 FEBRUARY 2006 Page 8 of 13

The aircraft was energized and again they tried to turn the twist grip
without activating the solenoid and it was not possible.
Power turbine rotation was free without evidence of metal spatter, blade
tip rubbing or visual evidence of over temperature and showed a positive
connection to the main gear box drive.
Functioning of the cyclic and collective controls confirmed that the
control systems from the pilot inputs to the hydraulic servos were
correctly connected and capable of functioning appropriately.
With the battery selected 'ON' it was noted that appropriate pitch change
movement of the blade roots took place when the cyclic and collective
controls were operated.
They activated the solenoid and turned the twist grip to off position and
the indication on the quadrant was +1 degrees. See figure 5 below.
Figure 5: View of the fuel control unit (FCU) quadrant.
The operation of the anticipator was checked and found operating
normally.
When moving the collective up and down and checking the indication on
the quadrant of the anticipator, the reaction was normal.
The twist grip was moved to idle position and the indication on the
quadrant was 28º. See figure 6 and 7 below.
CA 12-12b 23 FEBRUARY 2006 Page 9 of 13

Figure 6: Twist grip at idle position.
Figure 7: View of the fuel control unit (FCU) quadrant at 28º.
Fuel sample from the fuel tank and from the fuel filter bowl were taken
and analysed > no anomaly found.
Both fuel filters on the engine were removed and inspected > no
anomaly found.
CA 12-12b 23 FEBRUARY 2006 Page 10 of 13

The airframe fuel strainer was free from any contamination.
FCU control lever input connection satisfactory.
Aircraft booster pump activated and no fuel leaks noticed.
Anticipator input connection satisfactory.
The rigging of the fuel control was found to be in compliant with the
settings specified.
Oil tank sump electrical magnetic plug was contamination free.
Engine oil filter was removed and inspected > no anomaly was found.
Oil above minimum level.
No evidence of any in-flight fuel or oil leaks.
The free rotation of the compressor was checked > smooth rotation
with no rubbing.
Boroscopic inspection did not show any evidence of abnormal carbon
accumulation or any sign to suspect adverse combustion.
1.17 Organisational and management Information:
1.17.1 This was a training flight.
1.17.2 The last MPI (Mandatory periodic inspection) that was carried out on the helicopter
prior to the accident was certified at 2131.4 hours on 07 April 2010 by the AMO
(Aircraft Maintenance Organisation). The person who certified the task held a valid
approved person accreditation from the CAA as well as an AME (Aircraft Maintenance
Engineer) licence.
1.18 Additional information:
1.18.1 None.
1.19 Useful or effective investigation techniques:
1.19.1 None.
2 ANALYSIS:
2.1 Available information indicated that fine weather conditions prevailed in the area at the
time of the flight and subsequent accident. The prevailing weather conditions were
therefore not considered to have had any bearing on the accident.
CA 12-12b 23 FEBRUARY 2006 Page 11 of 13

2.2 The helicopter was properly maintained and no documented evidence was found
indicating any defect or malfunction of the helicopter prior the flight that could have
contributed to or caused the accident. The helicopter had flown a total of 10.4 hours
since the last maintenance inspection was certified.
2.3 Both pilots held a valid pilot's licences as well as valid aviation medical certificates that
were issued by a SA CAA accredited medical examiner. After the accident the
helicopter was recovered to a facility where various tests and analysis were carried out
and the investigation did not reveal any deficiencies. Both pilots held valid pilot's
licences as well as valid aviation medical certificates that were issued by an SACAA-
accredited medical examiner. After the accident, the helicopter was recovered to a
facility where various tests and analyses were carried out, and the investigation did not
reveal any deficiencies.
2.4 The IIC proposed to the regulator that the engine be shipped to France for further
analysis (test cell run), but this was not approved. In conclusion, the investigation could
not establish any conclusive reason why the engine stopped/flamed out; however,
unintentional shut-down of the engine could not be eliminated as a possible or
contributing factor to this accident.
3. CONCLUSION:
3.1 Findings:
i. Both pilots had Airline transport licences with the aircraft type endorsed in their
logbooks.
ii. The pilots were involved in a training flight under Visual flight Rules (VFR) by
day.
iii. Both pilots had ratings at the time of the accident.
iv. The weather conditions were favorable for VFR flight.
v. The Instructor׳s medical was valid with restrictions to put on Corrective lenses
at the time of the accident.
vi. The aircraft was involved in two (2) incidents.
vii. All control surfaces were accounted for and there was no evidence of any
defect or malfunction on the aircraft that could have contributed or have caused
the accident.
viii. The accident was considered survivable.
CA 12-12b 23 FEBRUARY 2006 Page 12 of 13

3.2 Probable cause/s:
3.2.1 Unsuccessful autorotation resulting into hard landing due to undetermined loss of
engine power.
3.3 Appendices:
3.3.1 Nil.
4. SAFETY RECOMMENDATIONS:
4.1 None.
Compiled by:
Frans Motaung
for the Commissioner for Civil Aviation
Date: ………………….………..
Investigator-in-charge: ………………………… Date: …………………………..
Co-investigator: ………………………………… Date: ……………….…………
CA 12-12b 23 FEBRUARY 2006 Page 13 of 13